A year after Congress agreed to spend billions of dollars to encourage a national switch to electronic health records, many doctors and hospitals have grown skeptical of the pace and details of the plan.
Medical societies, both large and small, say that federal officials are pushing doctors to phase out paper charts too quickly. Some rural health organizations fear the program could exacerbate a "digital divide" by concentrating the funding in elite hospitals that already computerize their records. Even some of the elite hospital systems aren't satisfied, seeking help from lawmakers to plead their case for more money.
"I don't think any of the recipients are happy," said Robert Tennant, a senior policy advisor with the Medical Group Management Association, which represents medical practices with nearly 275,000 doctors.
Louis Wenzlow, of the Rural Wisconsin Health Network, said he is disturbed that the largest incentive payments may flow to urban medical centers that have already gone electronic and don't need seed money. "This is completely inconsistent with the goals of the program," Wenzlow said.
The Obama administration is counting on widespread adoption of digital records to further its larger health care reform goals. As part of the economic stimulus bill, the government plans to spend up to $27 billion over the next five years. Hospitals could qualify for millions starting this fall and doctors could receive up to $44,000 each beginning next year.
Though the program is voluntary, doctors and hospitals that fail to go paperless by 2016 face cuts in their Medicare payments as a penalty.
Officials at the federal Office of National Coordinator, the agency that is responsible for developing health information technology, did not respond to requests for comment for this article.
Proponents of the stimulus program see digital health records as a pathway to higher-quality, lower-cost medicine and hope to create a digital file for every American by 2014. While the plan enjoys widespread political support in Washington, it's been far less popular among community doctors and hospitals.
Much of the controversy has flared over a requirement that medical providers make "meaningful use" of digital records to collect any money.
The stimulus law created two advisory panels to help define "meaningful" use. Panel members are supposed to reflect a "balance among various sectors of the health care system so that no single sector unduly influences the recommendations."
But draft regulations issued Dec. 30 alarmed a host of medical groups by outlining tough goals--such as writing patient treatment orders electronically--that present technical challenges that may be difficult for many users to achieve for some time.
The American Hospital Association quickly complained that the regulations imposed "rigid standards and unrealistic time frames" and that even some advanced users might come up short.
Steven Findlay, a standards panel member from Consumers Union -- the nonprofit that publishes Consumer Reports magazine -- said the government must impose rigorous rules before sending out any checks, to avoid wasting tax dollars and to ensure the program lives up to expectations.
Officials can't simply funnel money to doctors and hospitals to "buy pieces of equipment and do a few things," said Findlay. "This whole process is about defining what we think will be of benefit to patients."
In drafting the stimulus law, Congress didn't distinguish between medical groups already using the technology and those starting from scratch, as many rural and smaller hospitals and doctors' offices are doing.
While rural medicine groups generally support the goals of the program, some contend that the advisory panels have been dominated by people from technology-savvy hospitals, who set the bar too high for less-experienced users. They argue that stimulus money would be better spent in areas that lag behind.
"Ironically, the ones that need it the most are the ones that would be precluded from getting in. That's one of our biggest concerns," said Brock Slabach, of the National Rural Health Association in Kansas City.
David Kibbe, a physician and consultant for the American Academy of Family Physicians, also said small medical offices "will be at a disadvantage" in getting wired up in time to qualify for reimbursements. This "poses a problem as to the success and effectiveness of the overall program," he said.
Some advisory panel members agree that some standards should be relaxed. "We have a real challenge in rural communities and small towns," said Gayle Harrell, a former Florida state representative who serves on the federal policy panel. "We're concerned that we're not giving enough flexibility."
Stan Huff, a physician and technology expert at Intermountain Healthcare in Salt Lake City who serves on the standards panel, acknowledged that advanced users, such as academic medical centers, have an edge. Huff said it was "hard to imagine people with no systems right now" qualifying, at least initially, for stimulus checks.
A few digital records pioneers--or those who began installing the devices before the stimulus bill was enacted--could receive windfall payments under the plan. The Kaiser Permanente health plan system, for example, has invested billions of dollars in digital technology and has used it as a marketing tool. Kaiser, the largest nonprofit health provider in the nation, employs more than 10,000 physicians and operates dozens of hospitals; each doctor and hospital could qualify for a separate stimulus payment.
Jamie Ferguson, who directs Kaiser's health information technology, said the health plan is "working toward" meeting the requirements to collect stimulus money. He said large medical systems such as Kaiser would get a much smaller percentage of their investments back than doctors in small medical practices.
Yet some other pioneers in using electronic health records have complained that the draft regulations penalize them by not allowing them to collect money for affiliated physicians who work in clinics and other offices owned by the hospitals.
On their behalf, 18 U.S. senators sent a letter on Feb. 9 asking Health and Human Services Secretary Kathleen Sebelius to restore this funding in the final regulations. They said that doing so was "critically important to our states as well as these early champions" of digital records.
Huff said that that even some hospitals which have recently purchased digital systems in hopes of making the first round of funding might have a tough time getting up to speed in time. Huff said installations take 18 months to two years at a minimum, and can face numerous delays and costly missteps.
"I think it's really probably a stretch to think that very many institutions could get there as fast as the schedule they laid out," said Huff, whose health-care system has often been cited by President Obama as a model.
Officials who run the Medicare program and have the final say over the meaningful use regulations, declined a request for an interview.
But in e-mail responses to questions posed by the Huffington Post Investigative Fund, Medicare official Tony Trenkle said the agency "could not, as it developed the proposed rule, know or predict in advance how various medical specialties will respond to the requirements for meeting meaningful use."
Trenkle said that comments on the regulations "are encouraged and will be given serious consideration in our development of the final rule." The agency expects to complete the process in the spring, he said.